Health: Doctor Visits That Should Be Free For Many

PHILADELPHIA (CBS) –You could be owed money from your doctor. Under the new health law, preventive care is supposed to be free–things like well visits, flu shots and cancer screenings. But free isn’t always free.

It’s a well visit for 9-month-old Nicole, and her mom Christina Bragiel is relieved she no longer has co-pays.

“I was surprised. I was like, ‘Really?’” said Christina.

Yes, really. Insurance companies are now required by law to pay for preventive care, which means things like physicals, immunizations, cholesterol screenings, mammograms and colonoscopies. But there are all kinds of exceptions and tons of confusion.

“I thought, ‘Oh, this is a mistake because it’s covered,’” said Jim Dungee, who was told his colonoscopy would be free.

“I got the first bill from the hospital–$388,” said Jim.

“Unfortunately, when we do the procedure and we find something it is no longer considered preventative, it becomes diagnostic,” said Dr. Giancarlo Mercogliano, a gastroenterologist with Main Line Health. He says that when polyps are found during a colonoscopy, they’re removed, and the screening becomes a treatment. Then, patients are often responsible for co-pays or deductibles.

“Frequently, patients are upset when they find out they have co-pays or deductibles,” said Dr. Mercogliano.

Mammograms are another source of confusion.

“It’s been a big problem,” said Dr. Jennifer Sabol, a breast surgeon at Lankenau Medical Center.

She says co-pays often kick in on additional screenings after something suspicious is found on a mammogram.

“That procedure is then called a diagnostic test. We’ve acknowledged the fact that there may be a problem, you come back that day as a scheduled procedure, and you may get additional pictures,” said Dr. Sabol.

Then there’s the problem with flu shots. They prevent influenza and should be free, except if you get the shot from an out of network provider, or you get it during a sick visit.

The list of exceptions goes on and on.

It pays to ask questions, even if you’ve already paid, because you could be eligible for a refund.

Stephanie told Jim, “They looked at your claim. There appears to have been a miscommunication.”

Jim says his insurance company told him his procedure would be covered 100-percent.
When 3 On Your Side pointed that out to an Aetna representative, they looked into it, and based on his insurance plan, they decided to cover his bill.

Jim said, “Thank you very much.”

The Affordable Care Act is rolling out over a period of years, and more screenings and services will be free. Aspirin and birth control will be covered soon, too.

The bottom line is to always ask your insurance company what’s covered.